The SBIRT dental intervention was developed as a collaborative effort by the multidisciplinary research team composed of behavioral scientists, a clinical psychologist, a motivational interviewing (MI) trainer, and both academic dentists and dental hygienists with clinical practice experience. The intervention-development process is discussed below.
Theoretical foundations for the intervention
The brief intervention developed here was based on two related theoretical foundations—MI and personalized normative feedback (PNF).
Central to our intervention are MI techniques used in intervention delivery. MI is a “client centered, directive style of counseling” (Miller and Rollnick, 2002
) that includes client-centered listening strategies, as well as the strategic use of questions, reflections, and affirmations to emphasize motivational client speech. Following from the fundamental MI tenet that resolution of ambivalence or “discrepancy” is the key to behavior change (Neal and Carey, 2004
), a first step in MI is often to “develop discrepancy” between the individual and some standard of comparison, often involving comparison with others’ behaviors. Furthermore, MI techniques such as expressing empathy, supporting self-efficacy, avoiding argumentation, and rolling with resistance serve to build on perceived discrepancy to motivate consideration of the pro’s and con’s of behavior change. Furthermore, consistent with self-perception theory (Bem, 1972
), MI avoids confrontation and promotes change talk in which the client voices possible reasons for change.
Complementing the MI approach, PNF regarding the individual’s drinking is used to generate discrepancy. PNF has been used extensively in the research on college student drinking, where heavy drinking students often perceive other students as drinking more than they do (cf. Baer and Carney, 1993
). Interventions based on PNF thus provide individuals with feedback about how their drinking is compared with peer-drinking norms (Moreira et al., 2009
PNF has theoretical roots in self-regulation theory (Kanfer, 1970
). As elaborated by Miller and Brown (1991)
, self-regulation stages include the following: informational input, self-evaluation, and additional processes involving perceived discrepancy and efforts to resolve discrepancy. In this formulation, PNF (as “informational input”) plays a key role in providing comparisons with others’ drinking behaviors to develop discrepancy and initiate change processes. PNF has commonly been incorporated into MI-based interventions, using “personalized feedback reports” (cf. Walters and Neighbors, 2005
), providing a visual summary of the individual’s drinking (e.g. overall quantity/frequency and peak drinking), normative comparisons (e.g. amount consumed in relation to peers), often supplemented by associated negative consequences (e.g. tolerance, dependence, and alcohol-related problems).
Based on these theoretical foundations, we developed a feedback report providing personalized information regarding the individual’s drinking compared to national gender-specific norms as well as estimates of oral cancer risk associated with current drinking and smoking. This PNF was used to develop discrepancy, which, combined with other MI techniques, was used to elicit “change talk” in support of change.
Preliminary web-survey of dental practitioners’ acceptance of and perceived barriers to dental practice-based intervention approach
Further input to the intervention-development process was obtained through a web-based survey of Virginia dental practitioners (dentists and hygienists). Specifically, the web-survey addressed the acceptance of and perceived barriers to implementation of brief alcohol screening and intervention protocols in dental practice. Email invitations sent to membership lists provided by state dental and dental hygiene associations yielded usable data on a convenience sample of 257 respondents (164 dentists and 93 dental hygienists).
Relevant to intervention feasibility and development (Neff et al., 2010
), over 80 percent of both dentists and hygienists agreed or strongly agreed that heavy drinking is an important problem in dental practice. At the same time, both practitioner groups agreed that they were unaware of best strategies to help patients reduce heavy drinking (~75%) and that time constraints were an important concern regarding implementation (60%–62%).
Important differences between dentists and dental hygienists emerged as well (p < .05). Compared with dentists, dental hygienists had greater agreement (i.e. agree plus strongly agree) that (a) dental practice offered an “ideal opportunity” to screen and counsel about alcohol (76% vs. 61%); (b) screening and counseling for alcohol were appropriate in dental practice (71% vs. 55%); and (c) screening and counseling were appropriate for the dentist and dental hygienist’s roles (78% vs. 61%–64%). Dental hygienists (22%) were also less likely (43%) to be concerned about the effectiveness of alcohol screening and counseling than dentists.
Another finding relevant to intervention development was that dentists reported spending much less time with patients in the typical routine dental visit (compared with a more extensive initial visit) (average 12.32 ± 16.67 minutes; median: 5 minutes) than did hygienists (average of 40 ± 25.96 minutes; median: 40 minutes). These results suggest that the dental hygienist may have the greatest opportunity to conduct the intervention.
In sum, web-survey suggested the viability of dental practice-based interventions; however, barriers to intervention development and implementation included time constraints (i.e. the need for a very brief intervention) and training needs (i.e. a carefully structured protocol that could be easily utilized). Furthermore, the survey results support the use of the hygienist as interventionist.
Informal consultation with local dental practitioners regarding intervention approach
Finally, we conducted informal interviews with 2–3 dentists and 8–10 hygienists practicing in the surrounding Hampton Roads area, who also taught and supervised students part-time in the university’s Dental Hygiene Care Facility. These practitioners, interviewed individually or in small groups, were asked about the following issues: (a) the optimal length of the intervention, (b) where to incorporate the intervention in the visit, and (c) the respective roles of the hygienist and dentist in the intervention. These interviews indicated the following: (a) the need for a brief (3–5 minutes) intervention to minimize staff burden; (b) the use of the hygienist as interventionist, given their role in patient education and greater time with the patient during the dental visit; (c) incorporation of the intervention into the dental hygiene visit, before dental assessment and prophylaxis; (d) the use of the dentist to reinforce the hygienist’s message, and (e) provision of 8 hours of free continuing education (CE) credits for practitioners as an incentive for study participation.
The logic, structure, and delivery of the resulting SBIRT intervention are discussed below. The effectiveness of the brief intervention protocol described here is being examined in a controlled clinical trial, which randomizes practices to either SBIRT (Intervention; six practices) or assessment-only control conditions (five practices). Patients are assessed at baseline, 3 months, and 6 months to assess changes in alcohol use and alcohol-related problems. Study results will be reported in subsequent publications.